Patient Health Questionnaire and Suicide Ideation

SOURCE: Simon GE, Coleman KJ, Rossom RC, et al. Risk of suicide attempt and suicide death following completion of the Patient Health Questionnaire depression module in community practice. J Clin Psychiatry 2016;77:221-227.

The most recent guidance from the U.S. Preventive Services Task Force endorses screening for depression in all adults. The Patient Health Questionnaire (PHQ) is a commonly used tool for depression screening. An attractive benefit about this screening tool is that no permission is required for copying and using the screener in clinical practice.

Simon et al reviewed results of PHQ screenings of more than 500,000 adults obtained during the 2007-2012 interval. Patients had visited primary care clinicians as well as mental health specialists. Among this population, there were 9,203 nonfatal suicide attempts and 484 suicide deaths recorded during the same interval.

Patients who reported “thoughts of death or self-harm” on the PHQ as “not at all” were seven-fold less likely to attempt suicide in the 2 years following their screening than those who responded with “nearly every day” (0.5% vs. 3.5% rate of suicide attempt). A similar relative risk of suicide death — five-fold increase in the latter group — was found.

Over time, incidence of suicide declined but remained elevated as much as two- to five-fold for at least 18 months post-positive screening. Hence, clinicians should take positive results on the PHQ seriously and institute appropriate suicide prevention methods. Unfortunately, no depression or suicide screener is perfect. More than one-third of all suicide attempts and deaths occurred within 30 days of responses by screenees who had answered “not at all” to the PHQ question, “In the past two weeks, have you had thoughts that you would be better off dead or of hurting yourself in some way?”

Pregabalin Improves Outcomes in Chronic Cough

SOURCE: Vertigan AE, Kapela SL, Ryan NM, et al. Pregabalin and speech pathology combination therapy for refractory chronic cough: A randomized controlled trial. Chest 2016;149:639-648.

Chronic cough without an evident etiology can be a challenging issue. Guidelines suggest etiologic considerations, including infectious, allergic, malignant, mechanical, and psychological issues. In the primary care setting, recommendations call for clinicians to consider a course of antihistamines/nasal steroids, inhaled short-acting beta-agonists, and proton pump inhibitors, respectively, to rule out occult allergic rhinitis/postnasal drip, cough-variant asthma, and gastroesophageal reflux disease. Speech pathology treatment (SPT) also has been shown to be effective in refractory cases. Unfortunately, even after such inclusive treatments, a not-insubstantial group of patients continues to have unexplained cough.

Vertigan et al performed a randomized, controlled trial of SPT combined with either pregabalin (up to 300 mg/d) or placebo in patients with refractory cough (n = 44). Treatment was administered for 14 weeks, and a follow-up visit one month post-treatment was performed to see if treatment effects persisted after discontinuation. Outcomes included cough frequency, severity, and quality of life, using recognized metrics.

Adding pregabalin to SPT improved cough severity and quality of life better than placebo. Encouragingly, improvements in outcomes were durable at the last visit, one month post-treatment. Pregabalin appears to provide meaningful improvement in cough for patients who have been refractory to other standard interventions.

A New Topical Treatment for Peyronie’s Disease

SOURCE: Twidwell J, Levine L. Topical treatment for acute phase Peyronie’s disease utilizing a new gel, H-100: A randomized, prospective, placebo-controlled pilot study. Int J Impot Res 2016;28:41-45.

Peyronie’s disease is characterized by scarring of the tunica albuginea, which may result in angulation and/or pain when the penis is erect. While mild Peyronie’s disease is largely inconsequential, unless the sufferer has cosmetic concerns about the appearance of the erect penis, moderate to severe Peyronie’s disease may produce sufficient penile angulation as to make successful intercourse difficult or impossible.

Surgical intervention to modify the culprit scar lesion from the tunica is often successful, but many patients prefer less invasive interventions. Tools that have had some success with scar dissolution, such as intralesional verapamil, have not proven consistently effective in clinical trials.

H-100 oil is a combination of nicardipine and superoxide dismutase dissolved in emu oil, which is reportedly a good agent for enhancing transdermal absorption. Nicardipine blocks collagen production, and superoxide dismutase reduces inflammation through scavenging of free radicals.

Study subjects (n = 24) were randomized to H-100 or placebo. Both agents were applied twice daily to the penile shaft. At the six-month endpoint of the trial, men who applied H-100 demonstrated significant improvements in penile curvature and reductions in erection pain. Treatment was well tolerated, with only one patient discontinuing due to a penile rash. H-100 is a promising agent for a vexing disorder that otherwise often requires surgical intervention.